Healthcare Provider Details

I. General information

NPI: 1730652108
Provider Name (Legal Business Name): EVAN PATRICK VICKERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4207
US

IV. Provider business mailing address

414 5TH AVE S
JACKSONVILLE BEACH FL
32250-5454
US

V. Phone/Fax

Practice location:
  • Phone: 904-702-6111
  • Fax:
Mailing address:
  • Phone: 843-425-5915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11000865
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: